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Emergency airway for difficult intubations
Be prepared, that old Boy Scout motto, is being applied with great success to operating room patients whose anatomy might make it difficult for physicians to help them breathe during surgery, Johns Hopkins researchers report in a new study.
The researchers showed that a comprehensive program designed to help physicians quickly identify and treat anesthetized patients in which placement of a tube is difficult has dramatically reduced the need for high-risk emergency surgical procedures to open obstructed airways. At the heart of the program is a rolling cart armed with most any supply a physician would need to navigate a difficult airway and restart breathing, from flexible scopes and long catheters to medications and a surgical airway kit, just in case. While it might sound simple, the standardized cart cuts out the need for operating room staff to race around during a crisis to track down the gear needed to get oxygen flowing again, says Lauren C. Berkow, MD, one of the study's leaders.
"It seems an obvious solution, but it's not what people are used to doing," says Berkow, an assistant professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine. "People had to run to five different places to get the right equipment. The stakes are pretty high. Oxygen is vital. Time is of the essence. You want to make sure you have everything you need and know how to use it when that patient with an emergency rolls through the door."
During the four years before Johns Hopkins put its difficult airway program into place, an average of 6.5 patients a year needed to have their airways opened surgically. Over the 11 years that followed, ending in December 2006, an average of just 2.2 patients a year needed the emergency procedure. In the past year, Berkow says, no patients at Johns Hopkins have needed unplanned emergency airway surgery.
The findings are in the December issue of the journal Anesthesia & Analgesia.
The cart is but one part of Hopkins' difficult airway program. Doctors have been educated how to spot someone with a potentially life-threatening obstruction and how to use the items on the cart to properly deal with it. When it is difficult to put a breathing tube in place for a particular patient, that information goes into the patient's electronic health record so future providers will be aware of and prepared to deal with potential problems.
The decrease in the number of surgical airway procedures at Hopkins occurred despite an increase in patients reported to have a "difficult airway" as well as an overall increase in the number of patients receiving anesthesia per year, Berkow says. Airway-related deaths also declined after the initiation of the program, but the difference was not statistically significant because of the small numbers.
More patients are appearing with difficult airways as the population gets older, sicker, and larger, all signals that inserting a breathing tube could be tricky, Berkow says. Presently, only 1%-10% of patients have difficult airways, she says. A miniscule number of those will require surgical intervention to ensure air is getting into the lungs.
"We took disorganization and created an organized, standardized system, which we've continued to adapt and update as new technology comes out," Berkow says, "We keep all of our staff updated on the system, and we found it improves outcomes."
According to the authors, the cart includes the following:
• Drawer One: Clamp, Rochester (one); Magill Forceps (one); Magill Forceps, small (one); Yankauer suction (two); intravenous catheters (18, 16, 14 gauge — one); cotton-tipped applicators (one); tongue blades (10); Steriglide™ (10); 10-mL syringes (one); 16-gauge needles (four); alcohol swabs (five); Lidocaine labels (one); Phenylephrine labels (10); Bivona swivel connector (one); mucosal atomization device (one); anti-fog solution (one); biopsy valve (one); suction valve (one); Lidocaine HCl, 4% (one); Lidocaine HCl, 0.5% (three vials); Phenylephrine, 1% (one vial); Glycopyrrolate, 0.02% (two vials); Lidocaine HCl, topical 2% (two vials); difficult airway ID bracelets (one bottle); Lidocaine, 2% jelly (three to four tubes); and Lidocaine, 2% (three vials).
• Drawer Two: Endotracheal tubes (sizes 6.0, 7.0, 8.0, 9.0 — three); emesis basin (one); suction catheter, 14F (three); endotracheal tube stylets (pediatric and adult sizes — four); light wand stylets (infant, child, and adult sizes — three); light wand handle (one); nasopharyngeal airways (sizes 6.5 F, 7.0 F, 7.5 F, 8.0 F — five); short laryngoscope handle (one); and Miller No. 4 laryngoscope blade (one).
• Drawer Three: Baby-safe ventilating bag (one); oxygen face mask, adult (one); oxygen tubing (one); nasal cannula (one); airway, Ovassapain (one); airway, Williams (one); O2 face mask, pediatric (one); and adult nebulizer (one).
• Drawer Four: LMA (sizes No. 1, No. 1.5, No. 2, No. 2.5, No. 3, No. 4, and No. 5 — seven).
• Drawer Five: Intubating LMA (one); cricothyrotomy kit (includes scalpel, Kelly clamp, and size 5.0-mm uncuffed endotracheal tube); and spare battery (one).
• Top and side of cart: Light source (one); 4.7-mm flexible fiberoptic scope (one); Aintree intubation catheter (one); and airway exchange catheter (8F, 11F — two).
The research was supported by funding from the Medic Alert Foundation and a grant from MCIC Vermont.